Incident Report

This incident reporting form cannot be used for incidents involving people under the age of 18 that require parental notification.

Name of Group *

Group Supervisor

Type of Report *

Hazard

Injury

Date of Incident *

Time of Incident *

Location of Incident

Person Completing Report *

Describe the incident/hazard and how it occurred, including full names of any people injured *

Was first aid or other action taken?

Yes

If yes, by whom?

What part of their body was injured (if applicable)

Details of Injury or Property Damage (including treatment given and referrals)

Further corrective action recommended:

Names of witnesses (if neccessary)

I declare the information in this report is true and correct. *

Yes

Any additional comments from witnesses, ministry leader or first aider

Thank you for filling out this incident reporting form! The office will follow it up soon. We appreciate your commitment to creating a culture of safety in our church.